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  • Question 1 - A 45-year-old man presents with fever, malaise, weight loss and myalgias that have...

    Incorrect

    • A 45-year-old man presents with fever, malaise, weight loss and myalgias that have been occurring for a month. You suspect polyarteritis nodosa and arrange for some lab investigations. Which of the following abnormality would most likely be present?

      Your Answer: Positive ANCA

      Correct Answer: Elevated creatinine

      Explanation:

      People with polyarteritis nodosa often exhibit anaemia of chronic disease. Leucocytosis and eosinophilia may also be present. ANCA is only rarely positive. As polyarteritis nodosa affects the kidneys as well, the creatinine is elevated in most cases.

    • This question is part of the following fields:

      • Musculoskeletal System
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  • Question 2 - A 32-year-old complains of pain in her hands bilaterally. Which of the following...

    Correct

    • A 32-year-old complains of pain in her hands bilaterally. Which of the following symptoms would point towards an inflammatory joint disease such as rheumatoid arthritis?

      Your Answer: Marked stiffness for more than an hour in the mornings

      Explanation:

      In rheumatoid arthritis (RA), clinical symptoms of joint stiffness, pain, and functional disability are commonly most severe in the early morning. These symptoms closely follow the circadian rhythm of the pro-inflammatory cytokine, interleukin (IL)-6. In RA, the increase in nocturnal anti-inflammatory cortisol secretion is insufficient to suppress ongoing inflammation, resulting in the morning symptoms characteristic of RA. Established diagnostic criteria for RA include prolonged morning stiffness that could last up to an hour. Loss of joint mobility, pain, malaise and swelling of finger joints are features that are not specific to rheumatoid arthritis, and are found in many other conditions.

    • This question is part of the following fields:

      • Musculoskeletal System
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  • Question 3 - A 56-year-old woman presents to the clinic complaining of shoulder pain that she...

    Incorrect

    • A 56-year-old woman presents to the clinic complaining of shoulder pain that she has been experiencing for the last 4 weeks. She does not remember getting injured previously. The pain worsens on movement especially when she is moving the arm quickly. At night, lying on the affected side is painful. Examination reveals no erythema or swelling. However, pain is felt on passive abduction between 60 to 120 degrees and she is unable to abduct the arm past 70-80 degrees. Flexion and extension are intact. What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Supraspinatus tendonitis

      Explanation:

      Supraspinatus tendinopathy is a common and disabling condition that becomes more prevalent after middle age and is a common cause of pain in the shoulder. A predisposing factor is resistive overuse. This patient has the classic painful arc that is a sign of shoulder impingement characteristic of supraspinatus tendonitis.

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      • Musculoskeletal System
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  • Question 4 - A 22-year-old man who has recently returned from a trip to Far East...

    Incorrect

    • A 22-year-old man who has recently returned from a trip to Far East presents with sore eyes and symmetrical joint pain in his knees, ankles and feet. Labs reveal an elevated ESR. The synovial fluid aspirate is sterile and has a high neutrophil count. What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Reactive arthropathy

      Explanation:

    • This question is part of the following fields:

      • Musculoskeletal System
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  • Question 5 - A 36-year-old man presents with severe pain in his right big toe which...

    Incorrect

    • A 36-year-old man presents with severe pain in his right big toe which is erythematous and swollen. He recently had an appendicectomy. Personal history reveals that he consumes 30 units of alcohol per week. Choose the most likely diagnosis.

      Your Answer:

      Correct Answer: Gout

      Explanation:

      Chronic alcoholism leads to increased levels of uric acid in the blood. Gout is caused by high levels of uric acid.

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      • Musculoskeletal System
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  • Question 6 - A 28-year-old female with a history of psoriatic arthritis would most likely have...

    Incorrect

    • A 28-year-old female with a history of psoriatic arthritis would most likely have which of the following hand conditions?

      Your Answer:

      Correct Answer: Nail dystrophy

      Explanation:

      Nail dystrophy (pitting of nails, onycholysis, subungual hyperkeratosis), dactylitis, sausage shaped fingers are most commonly seen with psoriatic arthropathy. There is asymmetric joint involvement most commonly distal interphalangeal joints. Uveitis and sacroiliitis may also occur. Arthritis mutilans may occur but is very rare. Cutaneous lesions may or may not develop. When they do, its usually much after the symptoms of arthritis.

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      • Musculoskeletal System
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  • Question 7 - A 41-year-old woman who has a history of SLE presents with a dry...

    Incorrect

    • A 41-year-old woman who has a history of SLE presents with a dry cough, dyspnoea and fever. She is being treated with a monthly dose of IV cyclophosphamide for Grade IV nephropathy. The last cyclophosphamide dose was 10 years ago. Lab investigations are as follows:
      WCC: 2.3 (lymphocyte count 0.7)
      Platelets: 81
      Hb: 10.5
      ESR: 56
      CRP: 43
      PO2: 7.2 kPa, PCO2: 3.6 kPa after walking out to the toilet.

      Chest X ray was unremarkable apart from some patchy pulmonary infiltration.
      What is the likely diagnosis?

      Your Answer:

      Correct Answer: Pneumocystis carinii pneumonia (PCP)

      Explanation:

      Pneumocystis carinii pneumonia, is an opportunistic fungal lung infection occurring almost exclusively in immunocompromised individuals. In 50% of cases, PCP is the first manifestation of AIDS (acquired immune deficiency syndrome), but it may be caused by other immunodeficiency disorders. PCP should be suspected in patients with a history of progressive dyspnoea and a dry cough with resistance to standard antibiotic treatment. Signs that support this diagnosis include a CD4 count < 200/μL, an increased beta-D-glucan level, and diffuse bilateral infiltrates on chest x-ray. Management of PCP includes high-dose trimethoprim/sulfamethoxazole (TMP/SMX), treatment of the underlying immunodeficiency disorder, and steroids in the case of severe respiratory insufficiency. TB is less likely to be present in this case as ESR is relatively low and chest x-ray appeared normal.

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      • Musculoskeletal System
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  • Question 8 - A 45-year-old female was diagnosed with a benign ovarian mass on her right...

    Incorrect

    • A 45-year-old female was diagnosed with a benign ovarian mass on her right side. She complained of inner thigh pain on her right side. Which of the following nerves is responsible for her inner thigh pain?

      Your Answer:

      Correct Answer: Obturator nerve

      Explanation:

      The obturator nerve is compressed due to the ovarian mass, this causes pain in the inner thigh because it innervates this area.

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      • Musculoskeletal System
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  • Question 9 - A 42-year-old female with a history of SLE presents with an exacerbation of...

    Incorrect

    • A 42-year-old female with a history of SLE presents with an exacerbation of wrist pain. Which of the following markers would be the most suitable for monitoring disease activity?

      Your Answer:

      Correct Answer: Anti-dsDNA titres

      Explanation:

      A high level of anti-dsDNA in the blood is strongly associated with lupus and is often significantly increased during or just prior to a flare-up. When the anti-dsDNA is positive and the person tested has other clinical signs and symptoms associated with lupus, it means that the person tested likely has lupus. This is especially true if an anti-Sm test is also positive.

      In the evaluation of someone with lupus nephritis, a high level (titre) of anti-dsDNA is generally associated with ongoing inflammation and damage to the kidneys.

      A very low level of anti-dsDNA is considered negative but does not exclude a diagnosis of lupus. Only about 65-85% of those with lupus will have anti-dsDNA.

      Low to moderate levels of the autoantibody may be seen with other autoimmune disorders, such as Sjögren syndrome and mixed connective tissue disease (MCTD).

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      • Musculoskeletal System
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  • Question 10 - A 34-year-old lady presented with complaints of generalised body ache, arthritis, dryness of...

    Incorrect

    • A 34-year-old lady presented with complaints of generalised body ache, arthritis, dryness of eyes and mouth. The most likely diagnosis would be?

      Your Answer:

      Correct Answer: Primary Sjögren's syndrome

      Explanation:

      Sjogren syndrome is characterised by keratoconjunctivitis sicca, dry mouth and generalised body aches. It is one of the connective tissue diseases and has positive auto Ro and La antibodies.

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      • Musculoskeletal System
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  • Question 11 - A 67-year-old man reports weight loss. Labs show a raised alkaline phosphatase at...

    Incorrect

    • A 67-year-old man reports weight loss. Labs show a raised alkaline phosphatase at 290 U/L (normal range 35-120). Plain radiographs reveal sclerotic lesions of the bone. Which of the following is the most likely cause of these findings?

      Your Answer:

      Correct Answer: Prostate cancer

      Explanation:

      Osteoblastic (or sclerotic) bony metastases, characterized by deposition of new bone, present in prostate cancer, carcinoid, small cell lung cancer, Hodgkin lymphoma or medulloblastoma. The other cancers listed in the options are osteolytic.

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      • Musculoskeletal System
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  • Question 12 - A 52-year-old shopkeeper presents with pain in her hands. Examination reveals plaques on...

    Incorrect

    • A 52-year-old shopkeeper presents with pain in her hands. Examination reveals plaques on the extensor surfaces of her upper limbs and a telescoping deformity of both index fingers. Nails show pitting and horizontal ridging. The patient is most likely suffering from which of the following?

      Your Answer:

      Correct Answer: Arthritis mutilans

      Explanation:

      Arthritis mutilans is a rare (occurs in only 5% of the patients) and extremely severe form psoriatic arthritis characterized by resorption of bones and the consequent collapse of soft tissue. When this affects the hands, it can cause a phenomenon sometimes referred to as ‘telescoping fingers.’ The associated nail changes are also characteristic of arthritis.

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      • Musculoskeletal System
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  • Question 13 - Which of the following features occurs very less frequently with drug induced lupus?...

    Incorrect

    • Which of the following features occurs very less frequently with drug induced lupus?

      Your Answer:

      Correct Answer: Glomerulonephritis

      Explanation:

      Drug induced lupus typically presents with pulmonary involvement and no renal or neurological involvement. Hence glomerulonephritis would be highly unlikely in this case. Rash and arthralgias are classic presentations. Pleurisy can be present as pulmonary involvement may occur with DILE.

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      • Musculoskeletal System
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  • Question 14 - A 43-year-old female presents with an array of symptoms including weakness, lethargy, dysphagia,...

    Incorrect

    • A 43-year-old female presents with an array of symptoms including weakness, lethargy, dysphagia, dry mouth, gritty sensation in her eyes and increased photosensitivity. In order to confirm the suspected diagnosis, which of the following tests should be performed?

      Your Answer:

      Correct Answer: Labial gland biopsy

      Explanation:

      To confirm the diagnosis, especially in patients with negative anti-Ro or anti-La antibodies, labial gland biopsy is done. In performing a labial biopsy, the surgeon typically makes a shallow 1/2 inch wide incision on either side of the inner lip after numbing the area with a local anaesthetic. Schirmer’s test determines whether the eye produces enough tears to keep it moist. This test can be done for ocular symptoms of Sjogren syndrome but is of no diagnostic importance as it can be positive with many other diseases.

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      • Musculoskeletal System
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  • Question 15 - A 56-year-old obese female presents due to moderate pain in her finger joints...

    Incorrect

    • A 56-year-old obese female presents due to moderate pain in her finger joints which occurs mostly at the end of the day which gets better with rest. There is also some associated swelling. On examination, there is enlargement of her distal interphalangeal joints and tenderness to palpation. Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Osteoarthritis

      Explanation:

    • This question is part of the following fields:

      • Musculoskeletal System
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  • Question 16 - A 60-year-old diabetic female patient presented with spasmodic pain in her left thigh...

    Incorrect

    • A 60-year-old diabetic female patient presented with spasmodic pain in her left thigh and calf muscle. During examination the doctor noticed that the femoral and popliteal pulses were absent on the left side. Which of the following vessels is most probably occluded?

      Your Answer:

      Correct Answer: External Iliac Artery

      Explanation:

      The external iliac artery supplies both the thigh and calf muscles. The absence of pulses in femoral and popliteal vessels indicates the obstruction of the external iliac artery.

    • This question is part of the following fields:

      • Musculoskeletal System
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  • Question 17 - A 43-year-old man with hemochromatosis presents with a painful and swollen right knee....

    Incorrect

    • A 43-year-old man with hemochromatosis presents with a painful and swollen right knee. X-ray shows extensive chondrocalcinosis but no fracture. Given the most likely diagnosis, which of the following would be present in the joint fluid aspirate?

      Your Answer:

      Correct Answer: Positively birefringent rhomboid-shaped crystals

      Explanation:

      Pseudogout is a paroxysmal joint inflammation due to calcium pyrophosphate crystal deposition (calcium pyrophosphate dihydrate). Arthrocentesis should be performed, especially in acute cases.
      Polarized light microscopy: detection of rhomboid-shaped, positively birefringent CPPD crystals.
      Synovial fluid findings: 10,000-50,000 WBCs/μL with > 90% neutrophils.
      X-ray findings: cartilage calcification of the affected joint (chondrocalcinosis).
      Fibrocartilage (meniscus, annulus fibrosus of intervertebral disc) and hyaline cartilage (joint cartilage) may be affected.

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      • Musculoskeletal System
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  • Question 18 - A 28-year-old male is complaining about sore feet and lower back pain. He...

    Incorrect

    • A 28-year-old male is complaining about sore feet and lower back pain. He says it feels like walking on gravel. He also mentioned have some urethral discharge that he had not received any treatment for. He had a holiday in Morocco recently. What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Sjogren's Syndrome

      Explanation:

      This is a case of Sjogren Syndrome (aka Reiter’s disease). It is characterised by a triad of: seronegative arthritis mostly sacroiliitis (walking on gravel reflects planter fasciitis), urethritis and conjunctivitis. Sjogren Syndrome usually follows gastroenteritis or non specific urethritis. On the other hand gonococcal arthritis usually occurs in patients who are systemically unwell.

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      • Musculoskeletal System
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  • Question 19 - A 45-year-old male presents with lower backache and pain in his hips. Blood...

    Incorrect

    • A 45-year-old male presents with lower backache and pain in his hips. Blood tests are normal except for elevated serum alkaline phosphatase which is 1200 IU/l (45-105). Radiological examination shows combined osteolytic and osteosclerotic lesions. What is the most common site of occurrence of this disease?

      Your Answer:

      Correct Answer: Pelvis

      Explanation:

      The patient most likely suffers from Paget’s disease of the bone as his radiological examination shows both osteolytic and osteosclerotic lesions. Any bone or bones can be affected, but Paget’s disease occurs most frequently in the pelvis > lumbar spine > femur > thoracic spine > sacrum > skull > tibia.

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      • Musculoskeletal System
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  • Question 20 - A 22-year-old man is being evaluated for chronic lower backache. Which of the...

    Incorrect

    • A 22-year-old man is being evaluated for chronic lower backache. Which of the following would most strongly point towards the diagnosis of ankylosing spondylitis?

      Your Answer:

      Correct Answer: Reduced lateral flexion of the lumbar spine

      Explanation:

      Ankylosing spondylitis (spondylarthritis) is a chronic inflammatory disease of the axial skeleton that leads to partial or even complete fusion and rigidity of the spine. Males are disproportionately affected and upwards of 90% of patients are positive for the HLA-B27 genotype, which predisposes to the disease. The most characteristic early finding is pain and stiffness in the neck and lower back, caused by inflammation of the vertebral column and the sacroiliac joints. The pain typically improves with activity and is especially prominent at night. Other articular findings include tenderness to percussion and displacement of the sacroiliac joints (Mennell’s sign), as well as limited spine mobility, which can progress to restrictive pulmonary disease.
      The most common extra-articular manifestation is acute, unilateral anterior uveitis. Diagnosis is primarily based on symptoms and x-ray of the sacroiliac joints, with HLA-B27 testing and MRI reserved for inconclusive cases. There is no curative treatment, but regular physiotherapy can slow progression of the disease. Additionally, NSAIDs and/or tumour necrosis factor-? inhibitors may improve symptoms. In severe cases, surgery may be considered to improve quality of life. The spine adopts a bamboo shape, not lordosis. The pain usually improves as the day progresses. leg raise test causes pain in cases of meningitis etc not in this case.

    • This question is part of the following fields:

      • Musculoskeletal System
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  • Question 21 - Psoriatic arthropathy most commonly presents with which of the following types of arthritis?...

    Incorrect

    • Psoriatic arthropathy most commonly presents with which of the following types of arthritis?

      Your Answer:

      Correct Answer: Peripheral asymmetric oligoarthropathy

      Explanation:

      Most patients with psoriatic arthritis present with monoarthritis or asymmetric oligoarthritis. The most common form of the disease is the one involving a few joints of the peripheral skeleton with a distinct asymmetry of symptoms. Involvement of the smaller joints of the hands and feet, especially distal interphalangeal joints, seems to be a characteristic feature. Arthritis mutilans is a rare and severe complication of psoriatic arthritis.

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      • Musculoskeletal System
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  • Question 22 - A 36-year-old man arrives at the clinic complaining of pain and swelling of...

    Incorrect

    • A 36-year-old man arrives at the clinic complaining of pain and swelling of the left knee, ankles and right hallux. He has acute conjunctivitis, and dysuria. He suffered from an episode of gastroenteritis two weeks back. Clinical examination shows left Achilles tendonitis and right plantar fasciitis. Radiological examination reveals left sacroiliitis, with evidence of enthesitis, joint erosions and periostitis. HLA-B27 is positive. Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Reiter's syndrome

      Explanation:

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      • Musculoskeletal System
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  • Question 23 - A 56-year-old woman taking procainamide develops drug induced erythematosus. Which of the following...

    Incorrect

    • A 56-year-old woman taking procainamide develops drug induced erythematosus. Which of the following features is the most characteristic of this condition?

      Your Answer:

      Correct Answer: It may occur with chlorpromazine

      Explanation:

      Drug induced lupus is usually positive for antinuclear and antihistone antibodies, typically without renal or neurologic involvement. However, pulmonary involvement is common. Drugs that can induce lupus include isoniazid, hydralazine, procainamide, chlorpromazine, and other anticonvulsants.

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      • Musculoskeletal System
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  • Question 24 - A 35-year-old female complains of headache at the back of her head that...

    Incorrect

    • A 35-year-old female complains of headache at the back of her head that has been occurring for several days and pain on neck flexion. She works as a housemaid. Which of the following is the most likely cause of her presentation?

      Your Answer:

      Correct Answer: Cervical spondylosis

      Explanation:

      Cervical spondylosis is a general term for age-related wear and tear affecting the spinal disks in your neck. As the disks dehydrate and shrink, signs of osteoarthritis develop, including bony projections along the edges of bones (bone spurs). Cervical spondylosis is very common and worsens with age.

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      • Musculoskeletal System
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  • Question 25 - A 70-year-old woman accidentally fell and was brought to the orthopaedics department. Investigations...

    Incorrect

    • A 70-year-old woman accidentally fell and was brought to the orthopaedics department. Investigations reveal a fracture of the neck of the humerus. Which artery may most likely be injured?

      Your Answer:

      Correct Answer: Circumferential artery

      Explanation:

      Circumferential artery provides the blood supply to the neck of the femur. Damage to the artery may lead to avascular necrosis of the femoral neck or head.

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      • Musculoskeletal System
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  • Question 26 - An 81-year-old woman had fallen down in her house. She is now unable...

    Incorrect

    • An 81-year-old woman had fallen down in her house. She is now unable to walk. An x-ray was done on her left hip joint, which showed a fracture in the neck of the femur. Which nerve is most likely to be injured?

      Your Answer:

      Correct Answer: Sciatic nerve

      Explanation:

      Femoral neck fractures are common injuries that most often result from low-energy falls in the elderly; however, they also can occur in young patients as a result of high-energy mechanisms

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      • Musculoskeletal System
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  • Question 27 - An 80-year-old female, previously diagnosed with polymyalgia rheumatica 18 months back, presents to...

    Incorrect

    • An 80-year-old female, previously diagnosed with polymyalgia rheumatica 18 months back, presents to the outpatient clinic with bilateral shoulder stiffness and generalized myalgia. The ESR was found to be 60 mm/1st hour at the time of presentation. Prednisolone therapy was initiated at a daily dose of 15 mg along with Calcium and Vitamin supplementation. She reported resolution of her symptoms in one week. However the symptoms relapsed when the prednisolone dose was reduced below the current dose of 12.5 mg daily. How should she be ideally managed?

      Your Answer:

      Correct Answer: Continue the current dose of prednisolone and start methotrexate

      Explanation:

      Polymyalgia rheumatica, a syndrome characterized by proximal muscle pain and stiffness in older persons, generally is treated with prednisone. Dosages of 15 to 25 mg of prednisone per day can reduce inflammation considerably, although many patients relapse when therapy is tapered. Long-term (18 to 36 months) steroid treatment has been recommended by several studies, but this can result in multiple side effects, including osteoporosis, hypertension, cataracts, and hyperglycaemia. Methotrexate has been used to reduce inflammation in rheumatoid arthritis, systemic vasculitis, and giant cell arteritis, and in some studies has been combined with prednisone to treat polymyalgia rheumatica, decreasing the duration of treatment.

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      • Musculoskeletal System
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  • Question 28 - A 72-year-old retired fisherman presents with weakness of shoulders and hips over the...

    Incorrect

    • A 72-year-old retired fisherman presents with weakness of shoulders and hips over the last four months. Finger flexion is also weak but the extension is normal. There has been some difficulty swallowing liquids. Past medical history is not significant except for sexually transmitted disease that he caught some 40 years ago in South Pacific and got treated with antibiotics. He smokes and drinks one or two tots of rum at the weekend. Creatine kinase level is 125. Which of the following investigations is most significant in establishing a diagnosis?

      Your Answer:

      Correct Answer: Muscle biopsy with electron microscopy

      Explanation:

      Inclusion body myositis (IBM) is a progressive muscle disorder characterized by muscle inflammation, weakness, and atrophy (wasting). It is a type of inflammatory myopathy. IBM develops in adulthood, usually after age 50. The symptoms and rate of progression vary from person to person. The most common symptoms include progressive weakness of the legs, arms, fingers, and wrists. Some people also have weakness of the facial muscles (especially muscles controlling eye closure), or difficulty swallowing (dysphagia). Muscle cramping and pain are uncommon, but have been reported in some people. The underlying cause of IBM is poorly understood and likely involves the interaction of genetic, immune-related, and environmental factors. Some people may have a genetic predisposition to developing IBM, but the condition itself typically is not inherited. Elevated creatine kinase (CK) levels in the blood (at most ,10 times normal) are typical in IBM. Muscle biopsy may display several common findings including; inflammatory cells invading muscle cells, vacuolar degeneration, inclusions or plaques of abnormal proteins.

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      • Musculoskeletal System
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  • Question 29 - A 22-year-old nulliparous female presents with shortness of breath. She has a history...

    Incorrect

    • A 22-year-old nulliparous female presents with shortness of breath. She has a history of recurrent deep vein thrombosis. Complete blood count and clotting screen reveals the following results:
      Hb: 12.4 g/dl
      Plt: 137
      WBC: 7.5*109/l
      PT: 14 secs
      APTT: 46 secs
      Which of the following would be the most likely diagnosis?

      Your Answer:

      Correct Answer: Antiphospholipid syndrome

      Explanation:

      The combination of APTT and low platelets with recurrent DVTs make antiphospholipid syndrome the most likely diagnosis.

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      • Musculoskeletal System
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  • Question 30 - A 53-year-old female, longstanding case of rheumatoid arthritis comes for a review. Which...

    Incorrect

    • A 53-year-old female, longstanding case of rheumatoid arthritis comes for a review. Which of the following features are commonly associated with her condition?

      Your Answer:

      Correct Answer: Proximal interphalangeal joint involvement in the hands

      Explanation:

      Rheumatoid arthritis is a polyarthritis that results in symmetrical pain and swelling of the affected joints (also at rest). It particularly affects the metacarpophalangeal joints (MCPJs) and proximal interphalangeal joints (PIPJs), not the distal interphalangeal joints (DIPs).
      Ulcerative colitis and IBD are associated with seronegative arthritides, not RA. The condition can also cause various extra-articular manifestations such as ocular symptoms, rheumatoid nodules and pulmonary fibrosis. Scleritis, episcleritis and keratoconjunctivitis sicca are more common than uveitis. Early intervention with disease-modifying antirheumatic drugs (DMARDs) plays a decisive role in successful treatment.

    • This question is part of the following fields:

      • Musculoskeletal System
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